Hospital

Gateway Rehabilitation Hospital

Florence, KY · CCN 183030 · Rates published

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US ECHO FULL STUDY

This hospital’s price: $98 across 1 payer

Source: https://vrhgateway.com/wp-content/uploads/sites/14/2022/08/471023316_Gateway-Rehabilitation-Hospital_Standard-Charges.csv · observed 2026-07-30

This is the facility’s filed rate for this code. The comparison board’s estimate also adds the surgeon and anesthesia fees, so it is usually higher.

5,865 distinct procedures filed

29 distinct payers

204,476 rate rows

2026-07-30 last MRF observed

Data quality

200,019 of 204,476 rate rows are consumer-grade (97.8%)

4,457 rows are marked excluded from the consumer medians — these stay visible in the raw drill-down with the same reason shown here, so nothing is silently hidden.

Excluded — reason	Rows
template filing: same amount across many unrelated codes — excluded	4,297
exceeds 10× this hospital's gross charge — excluded from medians	142
below 25% of the Medicare reference for this code — likely a mislabeled per-diem or placeholder; excluded from medians	18

Data source & audit trail ↓ Download audit trail (JSON)

Source MRF file	https://vrhgateway.com/wp-content/uploads/sites/14/2025/09/471023316_vibra-hospital-of-florence_standardcharges.csv
Found on page	https://vrhgateway.com/about-us/price-transparency/
Discovered via	Discovered by HANK
Last fetch	not_modified · 2026-09-21
Content fingerprint	9e6df6cbdef70dc6… · 14,793,450 bytes · first seen 2026-05-08

Top 50 most expensive offerings

Outliers are flagged where this hospital's filed rate is ≥2× or ≤0.5× the national median for the same code.

Code	Description	Payers	Min $	Max $	Avg median	vs national
68875010201 OTHER	Gattex	13	$5.00	$137,212.00	$99,999.99	nat. median $100,000 1.0× median
407 OTHER	Traumatic Spinal Cord Injury M <24.50 And A >=61.50 Tier 2 C	14	$19,683.40	$89,195.16	$70,433.32	nat. median $16,665 outlier · 4.2×
1806 OTHER	Major Multiple Trauma With Brain Or Spinal Cord Injury M <30.50 Tier 2 C	14	$52,047.47	$66,214.74	$52,047.47	nat. median $2,186 outlier · 23.8×
55292070255 OTHER	Hemin For Injection	13	$27.85	$137,212.00	$51,333.70	nat. median $51,334 1.0× median
106 OTHER	Stroke M <41.50 And A <84.50 None A	14	$7,881.74	$55,103.74	$43,671.19	nat. median $3,044 outlier · 14.3×
505 OTHER	Non-traumatic Spinal Cord Injury M <39.50 Tier 2 C	14	$10,033.06	$44,490.24	$42,031.20	nat. median $14,495 outlier · 2.9×
59627033304 OTHER	Avonex Pen 30 mcg/0.5mL	13	$5.00	$137,212.00	$39,676.03	nat. median $39,676 1.0× median
59627022205 OTHER	Avonex	13	$10.22	$137,212.00	$39,676.03	nat. median $39,676 1.0× median
74368303 OTHER	Lupron Depot	13	$13,645.03	$137,212.00	$39,246.62	nat. median $39,247 1.0× median
205 OTHER	Traumatic Brain Injury M <35.50 Tier 3 D	14	$32,555.15	$45,530.04	$37,422.16	nat. median $14,633 outlier · 2.6×
105 OTHER	Stroke M <41.50 And A >=84.50 Tier 3 D	14	$30,921.60	$38,394.78	$36,591.73	nat. median $1,950 outlier · 18.8×
1504 OTHER	Pulmonary M <45.50 Tier 1 B	14	$27,065.00	$43,121.37	$34,999.14	nat. median $259 outlier · 135.2×
1705 OTHER	Major Multiple Trauma Without Brain Or Spinal Cord Injury M <36.50 Tier 3 D	14	$25,734.20	$41,321.97	$34,126.06	nat. median $3 outlier · 12500.4×
305 OTHER	Non-traumatic Brain Injury M <42.50 And A <78.50 Tier 1 B	14	$27,663.90	$45,208.80	$33,833.16	nat. median $68 outlier · 496.3×
74055402 OTHER	Humira(Cf) Pen	13	$20.88	$137,212.00	$33,228.58	nat. median $33,229 1.0× median
2144511 OTHER	Taltz Autoinjector	13	$13,645.03	$137,212.00	$33,195.46	nat. median $33,195 1.0× median
604 OTHER	Neurological M <43.50 Tier 1 B	14	$25,911.20	$47,216.61	$33,000.81	nat. median $11,636 outlier · 2.8×
304 OTHER	Non-traumatic Brain Injury M <42.50 And A >=78.50 Tier 2 C	14	$26,652.20	$53,084.63	$32,405.68	nat. median $9,874 outlier · 3.3×
1004 OTHER	Amputation Lower Extremity M <47.50 Tier 3 D	14	$28,938.70	$43,810.61	$32,341.00	nat. median $2,665 outlier · 12.1×
704 OTHER	Fracture Of Lower Extremity M <41.50 Tier 1 B	14	$11,977.30	$52,612.01	$32,333.44	nat. median $334 outlier · 96.9×
1805 OTHER	Major Multiple Trauma With Brain Or Spinal Cord Injury M >=30.50 And M <40.50 N…	14	$12,314.17	$32,259.50	$32,259.50	nat. median $2,374 outlier · 13.6×
504 OTHER	Non-traumatic Spinal Cord Injury M >=39.50 And M <48.50 Tier 2 C	14	$29,392.90	$64,759.70	$32,016.82	nat. median $15,186 outlier · 2.1×
2005 OTHER	Miscellaneous M <46.50 And A <77.50 Tier 1 B	14	$7,948.31	$42,112.72	$31,423.39	nat. median $2,886 outlier · 10.9×
25682000101 OTHER	Soliris	13	$13,645.03	$137,212.00	$31,310.40	nat. median $27,397 1.1× median
55513019201 OTHER	Neulasta Onpro	13	$13,645.03	$137,212.00	$30,806.35	nat. median $10,830 outlier · 2.8×
55513019001 OTHER	Neulasta 6 Mg	13	$13,645.03	$137,212.00	$30,806.35	nat. median $23,105 1.3× median
104 OTHER	Stroke M >=41.50 And M <50.50 Tier 3 D	14	$21,170.52	$38,743.63	$30,704.82	nat. median $1,688 outlier · 18.2×
1704 OTHER	Major Multiple Trauma Without Brain Or Spinal Cord Injury M >=36.50 And M <41.50…	14	$27,007.00	$64,062.27	$30,494.37	nat. median $2 outlier · 19801.5×
904 OTHER	Other Orthopedic M <44.5 Tier 2 C	14	$22,786.40	$38,684.22	$30,312.36	nat. median $2,146 outlier · 14.1×
2004 OTHER	Miscellaneous M <46.50 And A >=77.50 Tier 1 B	14	$3,262.84	$39,953.24	$29,811.83	nat. median $3,044 outlier · 9.8×
1404 OTHER	Cardiac M <45.50 Tier 2 C	14	$25,592.40	$42,909.45	$29,798.56	nat. median $3,015 outlier · 9.9×
1305 OTHER	Rheumatoid Other Arthritis M <51.50 And A <64.50 Tier 3 D	14	$27,178.50	$52,345.92	$29,618.44	nat. median $2,154 outlier · 13.8×
1204 OTHER	Osteoarthritis M <49.50 And A <74.50 Tier 3 D	14	$28,865.85	$48,373.21	$29,512.27	nat. median $2,886 outlier · 10.2×
204 OTHER	Traumatic Brain Injury M >=35.50 And M <49.50 Tier 2 C	14	$20,659.80	$32,166.60	$29,214.61	nat. median $7,505 outlier · 3.9×
805 OTHER	Replacement Of Lower-extremity Joint M <42.50 Tier 3 D	14	$26,267.70	$28,667.83	$28,590.85	nat. median $21 outlier · 1333.5×
1203 OTHER	Osteoarthritis M <49.50 And A >=74.50 Tier 3 D	14	$25,018.70	$33,290.23	$28,143.40	nat. median $12 outlier · 2320.1×
68982085005 OTHER	Octagam	13	$13,645.03	$137,212.00	$27,972.00	nat. median $27,972 1.0× median
603 OTHER	Neurological M >=43.50 And M <52.50 Tier 1 B	14	$15,200.88	$37,649.67	$26,313.82	nat. median $7,721 outlier · 3.4×
703 OTHER	Fracture Of Lower Extremity M >=41.50 And M <52.50 Tier 3 D	14	$18,511.18	$29,109.09	$26,093.35	nat. median $3 outlier · 7979.6×
303 OTHER	Non-traumatic Brain Injury M >=42.50 And M <52.50 None A	14	$20,966.91	$35,355.58	$25,983.92	nat. median $5,925 outlier · 4.4×
1003 OTHER	Amputation Lower Extremity M >=47.50 And M <55.50 Tier 3 D	14	$25,132.10	$39,857.40	$25,745.03	nat. median $2,374 outlier · 10.8×
903 OTHER	Other Orthopedic M >=44.50 And M <51.50 Tier 2 C	14	$22,491.50	$34,095.27	$25,297.59	nat. median $2,045 outlier · 12.4×
2003 OTHER	Miscellaneous M >=46.50 And M <55.50 Tier 2 C	14	$22,154.20	$45,039.91	$24,933.57	nat. median $3,044 outlier · 8.2×
1503 OTHER	Pulmonary M >=45.50 And M <56.50 Tier 3 D	14	$23,494.35	$26,579.25	$24,863.42	nat. median $156 outlier · 159.8×
1703 OTHER	Major Multiple Trauma Without Brain Or Spinal Cord Injury M >=41.50 And M <50.50…	14	$2,829.03	$26,943.27	$24,444.41	nat. median $3,015 outlier · 8.1×
1403 OTHER	Cardiac M >=45.50 And M <55.50 Tier 1 B	14	$8,701.15	$33,201.78	$24,319.28	nat. median $3,949 outlier · 6.2×
103 OTHER	Stroke M >=50.50 And M <63.50 Tier 1 B	14	$2,427.68	$30,357.87	$24,059.54	nat. median $6,553 outlier · 3.7×
203 OTHER	Traumatic Brain Injury M >=49.50 And M <61.50 Tier 3 D	14	$22,889.40	$30,186.84	$23,555.22	nat. median $6,408 outlier · 3.7×
502 OTHER	Non-traumatic Spinal Cord Injury M >=53.50 And M <60.50 Tier 1 B	14	$15,410.20	$31,529.30	$23,496.44	nat. median $11,780 2.0× median
503 OTHER	Non-traumatic Spinal Cord Injury M >=48.50 And M <53.50 Tier 3 D	14	$15,865.11	$25,445.47	$23,449.04	nat. median $21,386 1.1× median

Other procedures at this hospital

Browse this hospital's 5,865 published procedures. Use the slice to choose what to show, then sort or filter any column.

Sortable, filterable data table. Use the column headers to sort, the filter row to narrow results.
Code	Type	Description	Rate rows	Payers	Gross	Cash	Min $	Max $	Avg median	Last observed

68875010201	OTHER	Gattex	44	13	$99,999.99	—	$5.00	$137,212.00	$99,999.99	2026-05-09
407	OTHER	Traumatic Spinal Cord Injury M <24.50 And A >=61.50 Tier 2 C	48	14	$89,195.16	—	$19,683.40	$89,195.16	$70,433.32	2026-05-09
1806	OTHER	Major Multiple Trauma With Brain Or Spinal Cord Injury M <30.50 Tier 2 C	24	14	$66,214.74	—	$52,047.47	$66,214.74	$52,047.47	2026-05-09
55292070255	OTHER	Hemin For Injection	44	13	$51,333.70	—	$27.85	$137,212.00	$51,333.70	2026-05-09
106	OTHER	Stroke M <41.50 And A <84.50 None A	75	14	$42,038.43	—	$7,881.74	$55,103.74	$43,671.19	2026-05-09
505	OTHER	Non-traumatic Spinal Cord Injury M <39.50 Tier 2 C	70	14	$49,585.69	—	$10,033.06	$44,490.24	$42,031.20	2026-05-09
59627022205	OTHER	Avonex	44	13	$39,676.03	—	$10.22	$137,212.00	$39,676.03	2026-05-09
59627033304	OTHER	Avonex Pen 30 mcg/0.5mL	44	13	$39,676.03	—	$5.00	$137,212.00	$39,676.03	2026-05-09
74368303	OTHER	Lupron Depot	43	13	$39,246.62	—	$13,645.03	$137,212.00	$39,246.62	2026-05-09
205	OTHER	Traumatic Brain Injury M <35.50 Tier 3 D	48	14	$46,245.76	—	$32,555.15	$45,530.04	$37,422.16	2026-05-09
105	OTHER	Stroke M <41.50 And A >=84.50 Tier 3 D	49	14	$26,359.78	—	$30,921.60	$38,394.78	$36,591.73	2026-05-09
1504	OTHER	Pulmonary M <45.50 Tier 1 B	71	14	$54,479.64	—	$27,065.00	$43,121.37	$34,999.14	2026-05-09
1705	OTHER	Major Multiple Trauma Without Brain Or Spinal Cord Injury M <36.50 Tier 3 D	48	14	$42,684.13	—	$25,734.20	$41,321.97	$34,126.06	2026-05-09
305	OTHER	Non-traumatic Brain Injury M <42.50 And A <78.50 Tier 1 B	92	14	$34,740.06	—	$27,663.90	$45,208.80	$33,833.16	2026-05-09
74055402	OTHER	Humira(Cf) Pen	44	13	$33,228.58	—	$20.88	$137,212.00	$33,228.58	2026-05-09
2144511	OTHER	Taltz Autoinjector	43	13	$33,195.46	—	$13,645.03	$137,212.00	$33,195.46	2026-05-09
604	OTHER	Neurological M <43.50 Tier 1 B	95	14	$42,150.64	—	$25,911.20	$47,216.61	$33,000.81	2026-05-09
304	OTHER	Non-traumatic Brain Injury M <42.50 And A >=78.50 Tier 2 C	48	14	$53,084.63	—	$26,652.20	$53,084.63	$32,405.68	2026-05-09
1004	OTHER	Amputation Lower Extremity M <47.50 Tier 3 D	49	14	$40,263.94	—	$28,938.70	$43,810.61	$32,341.00	2026-05-09
704	OTHER	Fracture Of Lower Extremity M <41.50 Tier 1 B	95	14	$36,483.65	—	$11,977.30	$52,612.01	$32,333.44	2026-05-09
1805	OTHER	Major Multiple Trauma With Brain Or Spinal Cord Injury M >=30.50 And M <40.50 N…	25	14	$12,314.17	—	$12,314.17	$32,259.50	$32,259.50	2026-05-09
504	OTHER	Non-traumatic Spinal Cord Injury M >=39.50 And M <48.50 Tier 2 C	47	14	$64,759.70	—	$29,392.90	$64,759.70	$32,016.82	2026-05-09
2005	OTHER	Miscellaneous M <46.50 And A <77.50 Tier 1 B	95	14	$21,846.79	—	$7,948.31	$42,112.72	$31,423.39	2026-05-09
25682000101	OTHER	Soliris	43	13	$31,310.40	—	$13,645.03	$137,212.00	$31,310.40	2026-05-09
55513019001	OTHER	Neulasta 6 Mg	43	13	$30,806.35	—	$13,645.03	$137,212.00	$30,806.35	2026-05-09
55513019201	OTHER	Neulasta Onpro	43	13	$30,806.35	—	$13,645.03	$137,212.00	$30,806.35	2026-05-09
104	OTHER	Stroke M >=41.50 And M <50.50 Tier 3 D	73	14	$32,486.18	—	$21,170.52	$38,743.63	$30,704.82	2026-05-09
1704	OTHER	Major Multiple Trauma Without Brain Or Spinal Cord Injury M >=36.50 And M <41.50…	70	14	$52,459.74	—	$27,007.00	$64,062.27	$30,494.37	2026-05-09
904	OTHER	Other Orthopedic M <44.5 Tier 2 C	72	14	$38,684.23	—	$22,786.40	$38,684.22	$30,312.36	2026-05-09
2004	OTHER	Miscellaneous M <46.50 And A >=77.50 Tier 1 B	95	14	$27,028.51	—	$3,262.84	$39,953.24	$29,811.83	2026-05-09
1404	OTHER	Cardiac M <45.50 Tier 2 C	71	14	$42,909.45	—	$25,592.40	$42,909.45	$29,798.56	2026-05-09
1305	OTHER	Rheumatoid Other Arthritis M <51.50 And A <64.50 Tier 3 D	48	14	$52,348.92	—	$27,178.50	$52,345.92	$29,618.44	2026-05-09
1204	OTHER	Osteoarthritis M <49.50 And A <74.50 Tier 3 D	25	14	$48,373.21	—	$28,865.85	$48,373.21	$29,512.27	2026-05-09
204	OTHER	Traumatic Brain Injury M >=35.50 And M <49.50 Tier 2 C	70	14	$30,849.68	—	$20,659.80	$32,166.60	$29,214.61	2026-05-09
805	OTHER	Replacement Of Lower-extremity Joint M <42.50 Tier 3 D	25	14	$32,888.52	—	$26,267.70	$28,667.83	$28,590.85	2026-05-09
1203	OTHER	Osteoarthritis M <49.50 And A >=74.50 Tier 3 D	25	14	$33,290.23	—	$25,018.70	$33,290.23	$28,143.40	2026-05-09
68982085005	OTHER	Octagam	43	13	$27,972.00	—	$13,645.03	$137,212.00	$27,972.00	2026-05-09
603	OTHER	Neurological M >=43.50 And M <52.50 Tier 1 B	97	14	$30,403.96	—	$15,200.88	$37,649.67	$26,313.82	2026-05-09
703	OTHER	Fracture Of Lower Extremity M >=41.50 And M <52.50 Tier 3 D	50	14	$29,927.60	—	$18,511.18	$29,109.09	$26,093.35	2026-05-09
303	OTHER	Non-traumatic Brain Injury M >=42.50 And M <52.50 None A	72	14	$29,880.54	—	$20,966.91	$35,355.58	$25,983.92	2026-05-09
1003	OTHER	Amputation Lower Extremity M >=47.50 And M <55.50 Tier 3 D	25	14	$38,787.58	—	$25,132.10	$39,857.40	$25,745.03	2026-05-09
903	OTHER	Other Orthopedic M >=44.50 And M <51.50 Tier 2 C	71	14	$29,712.00	—	$22,491.50	$34,095.27	$25,297.59	2026-05-09
2003	OTHER	Miscellaneous M >=46.50 And M <55.50 Tier 2 C	71	14	$28,374.28	—	$22,154.20	$45,039.91	$24,933.57	2026-05-09
1503	OTHER	Pulmonary M >=45.50 And M <56.50 Tier 3 D	47	14	$24,448.37	—	$23,494.35	$26,579.25	$24,863.42	2026-05-09
1703	OTHER	Major Multiple Trauma Without Brain Or Spinal Cord Injury M >=41.50 And M <50.50…	47	14	$20,225.71	—	$2,829.03	$26,943.27	$24,444.41	2026-05-09
1403	OTHER	Cardiac M >=45.50 And M <55.50 Tier 1 B	72	14	$24,254.76	—	$8,701.15	$33,201.78	$24,319.28	2026-05-09
103	OTHER	Stroke M >=50.50 And M <63.50 Tier 1 B	77	14	$26,033.81	—	$2,427.68	$30,357.87	$24,059.54	2026-05-09
203	OTHER	Traumatic Brain Injury M >=49.50 And M <61.50 Tier 3 D	25	14	$25,785.60	—	$22,889.40	$30,186.84	$23,555.22	2026-05-09
502	OTHER	Non-traumatic Spinal Cord Injury M >=53.50 And M <60.50 Tier 1 B	94	14	$30,074.46	—	$15,410.20	$31,529.30	$23,496.44	2026-05-09
503	OTHER	Non-traumatic Spinal Cord Injury M >=48.50 And M <53.50 Tier 3 D	48	14	$20,672.63	—	$15,865.11	$25,445.47	$23,449.04	2026-05-09
1502	OTHER	Pulmonary M >=56.50 And M <68.50 Tier 3 D	48	14	$29,532.46	—	$21,365.50	$29,686.71	$23,152.59	2026-05-09
804	OTHER	Replacement Of Lower-extremity Joint M >=42.50 And M <51.50 Tier 3 D	48	14	$24,480.91	—	$20,146.60	$24,119.46	$23,036.68	2026-05-09
50633012011	OTHER	Digifab	44	13	$22,958.40	—	$29.66	$137,212.00	$22,958.40	2026-05-09
902	OTHER	Other Orthopedic M >=51.50 And M <63.50 Tier 1 B	94	14	$26,837.82	—	$18,834.40	$28,376.60	$22,458.04	2026-05-09
1702	OTHER	Major Multiple Trauma Without Brain Or Spinal Cord Injury M >=50.50 And M <57.50…	48	14	$27,546.14	—	$20,120.45	$27,546.14	$22,400.00	2026-05-09
602	OTHER	Neurological M >=52.50 And M <64.50 Tier 1 B	100	14	$32,749.03	—	$9,386.68	$31,952.36	$22,332.33	2026-05-09
78081881	OTHER	SandoSTATIN Lar Depot	43	13	$22,158.24	—	$13,645.03	$137,212.00	$22,158.24	2026-05-09
2002	OTHER	Miscellaneous M >=55.50 And M <66.50 Tier 3 D	97	14	$22,715.66	—	$18,416.20	$54,064.12	$21,843.00	2026-05-09
1202	OTHER	Osteoarthritis M >=49.50 And M <61.50 Tier 3 D	25	14	$28,722.52	—	$19,523.00	$28,722.52	$21,723.73	2026-05-09
302	OTHER	Non-traumatic Brain Injury M >=52.50 And M <65.50 Tier 2c	70	14	$19,749.23	—	$15,476.24	$23,509.71	$21,594.81	2026-05-09
702	OTHER	Fracture Of Lower Extremity M >=52.50 And M <61.50 Tier 3 D	48	14	$26,660.98	—	$19,245.10	$27,637.82	$21,218.58	2026-05-09
2840001	OTHER	Forteo	44	13	$20,591.47	—	$92.08	$137,212.00	$20,591.47	2026-05-09
803	OTHER	Replacement Of Lower-extremity Joint M >=51.50 And M <57.50 Tier 3 D	48	14	$22,648.53	—	$17,850.50	$22,764.88	$20,562.47	2026-05-09
1802	OTHER	Major Multiple Trauma With Brain Or Spinal Cord Injury M >=55.50 And M <67.50 T…	49	14	$27,483.93	—	$17,724.10	$27,483.93	$20,018.40	2026-05-09
1002	OTHER	Amputation Lower Extremity M >=55.50 And M <64.50 None A	24	14	$26,697.53	—	$19,685.59	$26,697.53	$19,685.59	2026-05-09
802	OTHER	Replacement Of Lower-extremity Joint M >=57.50 And M <63.50 Tier 3 D	26	14	$21,760.63	—	$16,461.07	$24,874.17	$19,116.81	2026-05-09
50458060901	OTHER	Invega Trinza	44	13	$19,046.87	—	$57.98	$137,212.00	$19,046.87	2026-05-09
1402	OTHER	Cardiac M >=55.50 And M <68.50 None A	50	14	$19,997.57	—	$13,542.13	$23,904.31	$18,845.14	2026-05-09
68982085004	OTHER	Octagam	43	13	$18,648.00	—	$13,645.03	$137,212.00	$18,648.00	2026-05-09
55513003201	OTHER	Aranesp	44	13	$18,576.00	—	$5.00	$137,212.00	$18,576.00	2026-05-09
1501	OTHER	Pulmonary M >=68.50 Tier 3 D	25	14	$20,977.62	—	$18,067.40	$20,977.62	$18,436.17	2026-05-09
401	OTHER	Traumatic Spinal Cord Injury M >=56.50 None A	24	14	$12,687.59	—	$12,687.59	$17,935.64	$17,935.64	2026-05-09
202	OTHER	Traumatic Brain Injury M >=61.50 And M <73.50 Tier 3 D	47	14	$17,614.30	—	$17,614.30	$18,913.94	$17,808.61	2026-05-09
102	OTHER	Stroke M >=63.50 And M <72.50 Tier 3 D	49	14	$13,801.57	—	$9,798.79	$18,665.58	$17,789.65	2026-05-09
78063998	OTHER	Cosentyx	44	13	$17,781.50	—	$5.00	$137,212.00	$17,781.50	2026-05-09
173089201	OTHER	Mepolizumab Injection	43	13	$17,706.38	—	$13,645.03	$137,212.00	$17,706.38	2026-05-09
2001	OTHER	Miscellaneous M >=66.50 Tier 1 B	94	14	$23,581.10	—	$14,837.90	$23,581.10	$17,664.08	2026-05-09
501	OTHER	Non-traumatic Spinal Cord Injury M >=60.50 Tier 3 D	48	14	$20,972.30	—	$15,916.90	$17,694.85	$17,484.22	2026-05-09
701	OTHER	Fracture Of Lower Extremity M >=61.50 Tier 3 D	24	14	$16,814.02	—	$16,814.02	$17,425.63	$17,425.63	2026-05-09
44206043820	OTHER	Privigen 10%	43	13	$17,379.84	—	$13,645.03	$137,212.00	$17,379.84	2026-05-09
1001	OTHER	Amputation Lower Extremity M >=64.50 Tier 3 D	24	14	$26,882.66	—	$17,346.00	$26,882.66	$17,346.00	2026-05-09
78081181	OTHER	SandoSTATIN Lar Depot	43	13	$16,912.46	—	$13,645.03	$137,212.00	$16,912.46	2026-05-09
301	OTHER	Non-traumatic Brain Injury M >=65.50 Tier 3 D	25	15	$44,702.82	—	$98.00	$44,702.41	$16,703.27	2026-07-30
50458056401	OTHER	Invega Sustenna 234 Mg	44	13	$16,697.76	—	$37.25	$137,212.00	$16,697.76	2026-05-09
74379902	OTHER	Humira	44	13	$16,614.29	—	$5.00	$137,212.00	$16,614.29	2026-05-09
944270006	OTHER	Gammagard Liquid	44	13	$16,273.92	—	$7.57	$137,212.00	$16,273.92	2026-05-09
601	OTHER	Neurological M >=64.50 Tier 3 D	51	14	$14,956.72	—	$15,562.80	$17,607.64	$15,880.43	2026-05-09
55513073001	OTHER	Denosumab 120 mg/1.7mL	44	13	$15,770.26	—	$5.00	$137,212.00	$15,770.26	2026-05-09
801	OTHER	Replacement Of Lower-extremity Joint M >=63.50 None A	26	14	$19,863.30	—	$12,735.98	$19,796.27	$15,726.86	2026-05-09
1401	OTHER	Cardiac M >=68.50 Tier 1 B	71	14	$15,735.61	—	$12,778.37	$21,395.74	$15,671.88	2026-05-09
901	OTHER	Other Orthopedic M >=63.50 Tier 3 D	48	14	$12,312.74	—	$10,437.74	$17,008.52	$15,561.91	2026-05-09
51759063010	OTHER	risperiDONE ER Inj 125 Mg/0.35	43	13	$15,375.36	—	$13,645.03	$137,212.00	$15,375.36	2026-05-09
24201040002	OTHER	Calcitonin,salmon Inj 400 Unit	44	13	$15,028.80	—	$5.00	$137,212.00	$15,028.80	2026-05-09
42367054032	OTHER	Ryanodex	43	13	$14,040.84	—	$12,987.77	$137,212.00	$14,040.84	2026-05-09
59148001971	OTHER	Abilify Maintena	44	13	$13,535.23	—	$5.00	$16,665.75	$13,535.23	2026-05-09
59148007280	OTHER	Abilify Maintena 400 Mg	44	13	$13,535.23	—	$12.68	$16,665.75	$13,535.23	2026-05-09
67457067502	OTHER	Miacalcin	43	13	$12,974.72	—	$12,001.61	$16,665.75	$12,974.72	2026-05-09
70539000102	OTHER	Tymlos	43	13	$12,801.60	—	$11,841.48	$16,665.75	$12,801.60	2026-05-09
55513022101	OTHER	Nplate 250 Mcg	43	13	$12,585.22	—	$11,641.33	$16,665.75	$12,585.22	2026-05-09
50474070062	OTHER	Cimzia	44	13	$12,239.24	—	$5.00	$16,665.75	$12,239.24	2026-05-09
55513011101	OTHER	Aranesp	44	13	$11,145.60	—	$22.44	$16,665.75	$11,145.60	2026-05-09
50458056301	OTHER	Invega Sustenna 156 Mg	44	13	$11,132.11	—	$5.00	$16,665.75	$11,132.11	2026-05-09
50458056101	OTHER	Invega Sustenna	44	13	$11,131.49	—	$115.78	$16,665.75	$11,131.49	2026-05-09
50458056001	OTHER	Invega Sustenna	44	13	$11,131.01	—	$125.22	$16,665.75	$11,131.01	2026-05-09
944265804	OTHER	Gammagard S-d 10 Gram	44	13	$10,764.48	—	$7.57	$16,665.75	$10,764.48	2026-05-09
61953000405	OTHER	Flebogamma Dif	44	13	$10,164.48	—	$5.00	$16,665.75	$10,164.48	2026-05-09
59148004580	OTHER	Abilify Maintena	44	13	$10,151.42	—	$5.00	$16,665.75	$10,151.42	2026-05-09
67457083306	OTHER	Pegfilgrastim-jmdb	43	13	$10,020.00	—	$9,268.50	$16,665.75	$10,020.00	2026-05-09
74364203	OTHER	Lupron Depot	43	13	$9,811.68	—	$9,075.81	$16,665.75	$9,811.68	2026-05-09
68982085003	OTHER	Octagam 10%	43	13	$9,324.00	—	$8,624.70	$16,665.75	$9,324.00	2026-05-09
58406003204	OTHER	EnbreL Sureclick	44	13	$9,148.70	—	$356.32	$16,665.75	$9,148.70	2026-05-09
24591401	OTHER	Dupixent Syringe	44	13	$9,127.68	—	$74.24	$16,665.75	$9,127.68	2026-05-09
44206043710	OTHER	Privigen 10%	43	13	$8,689.92	—	$8,038.18	$16,665.75	$8,689.92	2026-05-09
55513071001	OTHER	Prolia	43	13	$8,573.38	—	$7,930.38	$16,665.75	$8,573.38	2026-05-09
57970010001	OTHER	Dalbavancin Hcl	44	13	$8,539.82	—	$25.76	$16,665.75	$8,539.82	2026-05-09
50458056201	OTHER	Invega Sustenna 117 Mg	44	13	$8,348.78	—	$38.59	$16,665.75	$8,348.78	2026-05-09
31600	OTHER	Tracheostomy	43	13	$8,209.00	—	$7,593.32	$16,665.75	$8,209.00	2026-05-09
944270005	OTHER	Gammagard Liquid 10%	44	13	$8,136.96	—	$7.57	$16,665.75	$8,136.96	2026-05-09
64842072709	OTHER	Decitabine/Cedazuridine 35/100	44	13	$7,931.30	—	$39.95	$16,665.75	$7,931.30	2026-05-09
65757030001	OTHER	VivitroL	43	13	$7,877.33	—	$7,286.53	$16,665.75	$7,877.33	2026-05-09
55513000601	OTHER	Aranesp	44	13	$7,430.40	—	$359.04	$16,665.75	$7,430.40	2026-05-09
55513002801	OTHER	Aranesp	44	13	$7,430.40	—	$17.40	$16,665.75	$7,430.40	2026-05-09
59676082001	OTHER	Monovisc	43	13	$7,200.00	—	$6,660.00	$16,665.75	$7,200.00	2026-05-09
9029703	OTHER	Gelfilm 25x50mm	44	13	$7,140.96	—	$5.04	$16,665.75	$7,140.96	2026-05-09
517065001	OTHER	Injectafer	44	13	$6,862.56	—	$16.22	$16,665.75	$6,862.56	2026-05-09
3218811	OTHER	Orencia	43	13	$6,834.32	—	$6,321.74	$16,665.75	$6,834.32	2026-05-09
13533080071	OTHER	Gamunex-c	44	13	$6,804.00	—	$7.57	$16,665.75	$6,804.00	2026-05-09
65162091322	OTHER	Voriconazole Oral Susp (bulk)	43	13	$6,753.68	—	$6,247.15	$16,665.75	$6,753.68	2026-05-09
4026129	OTHER	Cellcept (160ml Bottle)	44	13	$6,628.18	—	$58.00	$16,665.75	$6,628.18	2026-05-09
2850101	OTHER	HumuLIN R U-500	80	13	$7,137.60	—	$7.12	$16,665.75	$6,602.28	2026-05-09
50484081015	OTHER	Regranex	43	13	$6,526.56	—	$6,037.07	$16,665.75	$6,526.56	2026-05-09
62935022305	OTHER	Leuprolide Acetate	44	13	$6,504.34	—	$1.50	$16,665.75	$6,504.34	2026-05-09
31722062921	OTHER	Atovaquone (Bulk Bottle)	44	13	$6,307.16	—	$5.56	$16,665.75	$6,307.16	2026-05-09
55513022301	OTHER	Romiplostim	43	13	$6,292.70	—	$5,820.75	$16,665.75	$6,292.70	2026-05-09
78043561	OTHER	Reclast 5 Mg	43	13	$6,283.44	—	$5,812.18	$16,665.75	$6,283.44	2026-05-09
23392102	OTHER	Botox	44	13	$6,201.60	—	$7.76	$16,665.75	$6,201.60	2026-05-09
44146	OTHER	Colec Part W Colopros W/colost	44	13	$5,934.18	—	$6.50	$16,665.75	$5,934.18	2026-05-09
50458030811	OTHER	RisperDAL Consta 50 Mg	43	13	$5,900.21	—	$5,457.69	$16,665.75	$5,900.21	2026-05-09
59338077501	OTHER	Feraheme 510 Mg	44	13	$5,729.38	—	$5.00	$16,665.75	$5,729.38	2026-05-09
57894003001	OTHER	Remicade 100 Mg	43	13	$5,605.54	—	$5,185.12	$16,665.75	$5,605.54	2026-05-09
44208	OTHER	Laparosc, Surg Colectomy, Part	44	13	$5,584.11	—	$231.45	$16,665.75	$5,584.11	2026-05-09
55513002704	OTHER	Aranesp	44	13	$5,572.80	—	$28.80	$16,665.75	$5,572.80	2026-05-09
61958180101	OTHER	Harvoni	44	13	$5,400.00	—	$25.80	$16,665.75	$5,400.00	2026-05-09
944265603	OTHER	Gammagard S-d 5 Gram	44	13	$5,382.24	—	$5.00	$16,665.75	$5,382.24	2026-05-09
82154044901	OTHER	Peginterferon Alfa-2a	43	13	$5,344.42	—	$4,943.59	$16,665.75	$5,344.42	2026-05-09
59676034001	OTHER	Procrit	43	13	$5,131.20	—	$4,746.36	$16,665.75	$5,131.20	2026-05-09
43246	OTHER	Peg	43	13	$4,875.00	—	$4,509.38	$16,665.75	$4,875.00	2026-05-09
61958150101	OTHER	Sovaldi	43	13	$4,800.00	—	$4,440.00	$16,665.75	$4,800.00	2026-05-09
68982085002	OTHER	Octagam	43	13	$4,662.00	—	$4,312.35	$16,665.75	$4,662.00	2026-05-09
50742031025	OTHER	Mafenide Acetate For Topical S	43	13	$4,661.36	—	$4,311.76	$16,665.75	$4,661.36	2026-05-09
169418113	OTHER	Semaglutide	43	13	$4,648.90	—	$4,300.23	$16,665.75	$4,648.90	2026-05-09
169413013	OTHER	Semaglutide Injection	43	13	$4,648.90	—	$4,300.23	$16,665.75	$4,648.90	2026-05-09
169477212	OTHER	Semaglutide (2 Mg/dose)	43	13	$4,648.90	—	$4,300.23	$16,665.75	$4,648.90	2026-05-09
65757040203	OTHER	Aristada	44	13	$4,637.50	—	$5.47	$16,665.75	$4,637.50	2026-05-09
65757040103	OTHER	Aristada	44	13	$4,633.98	—	$5.14	$16,665.75	$4,633.98	2026-05-09
65757040303	OTHER	Aristada	44	13	$4,633.96	—	$15.07	$16,665.75	$4,633.96	2026-05-09
65757040403	OTHER	Aristada	44	13	$4,586.84	—	$5.00	$16,665.75	$4,586.84	2026-05-09
66794015702	OTHER	Gablofen	44	13	$4,536.67	—	$9.12	$16,665.75	$4,536.67	2026-05-09
65054301	OTHER	Triesence 40 Mg	43	13	$4,531.20	—	$4,191.36	$16,665.75	$4,531.20	2026-05-09
50242005121	OTHER	Rituxan	43	13	$4,509.70	—	$4,171.48	$16,665.75	$4,509.70	2026-05-09
16110081230	OTHER	Fluoroplex 1 %	44	13	$4,454.16	—	$133.11	$16,665.75	$4,454.16	2026-05-09
50458030711	OTHER	RisperDAL Consta 37.5 Mg	43	13	$4,425.02	—	$4,093.14	$16,665.75	$4,425.02	2026-05-09
44206043605	OTHER	Privigen	43	13	$4,344.96	—	$4,019.09	$16,665.75	$4,344.96	2026-05-09
36569	OTHER	Picc Line Insertion	43	13	$4,308.48	—	$3,985.34	$16,665.75	$4,308.48	2026-05-09
59572042521	OTHER	Revlimid	43	13	$4,279.44	—	$3,958.48	$16,665.75	$4,279.44	2026-05-09
59572041500	OTHER	Revlimid	43	13	$4,279.44	—	$3,958.48	$16,665.75	$4,279.44	2026-05-09
59572041028	OTHER	Revlimid	43	13	$4,279.44	—	$3,958.48	$16,665.75	$4,279.44	2026-05-09
61958220101	OTHER	Epclusa	44	13	$4,272.00	—	$84.25	$16,665.75	$4,272.00	2026-05-09
44087002203	OTHER	Rebif 22 mcg/0.5mL	43	13	$4,226.26	—	$3,909.29	$16,665.75	$4,226.26	2026-05-09
44087004403	OTHER	Rebif	43	13	$4,226.26	—	$3,909.29	$16,665.75	$4,226.26	2026-05-09
42388002326	OTHER	Cabometyx	44	13	$4,093.57	—	$37.92	$16,665.75	$4,093.57	2026-05-09
42388002426	OTHER	Cabometyx	44	13	$4,093.57	—	$5.00	$16,665.75	$4,093.57	2026-05-09
42388002526	OTHER	Cabometyx	44	13	$4,093.57	—	$19.20	$16,665.75	$4,093.57	2026-05-09
310652401	OTHER	Byetta	44	13	$4,079.76	—	$190.56	$16,665.75	$4,079.76	2026-05-09
310651201	OTHER	Byetta	44	13	$4,079.76	—	$230.40	$16,665.75	$4,079.76	2026-05-09
944270004	OTHER	Gammagard Liquid 10%	44	13	$4,068.48	—	$7.57	$16,665.75	$4,068.48	2026-05-09
378972055	OTHER	Denavir 1 %	44	13	$3,897.55	—	$5.00	$16,665.75	$3,897.55	2026-05-09
62856070430	OTHER	Lenvima	44	13	$3,880.80	—	$35.66	$16,665.75	$3,880.80	2026-05-09
69098038	OTHER	Sutent	43	13	$3,853.62	—	$3,564.60	$16,665.75	$3,853.62	2026-05-09
73562011201	OTHER	Lipase/Protea/Amyl 20-63-84k U	44	13	$3,846.24	—	$6.37	$16,665.75	$3,846.24	2026-05-09
55513000504	OTHER	Aranesp	44	13	$3,715.20	—	$3,436.56	$16,665.75	$3,715.20	2026-05-09
55513002504	OTHER	Darbepoetin Alfa 100 M 100 Mcg	44	13	$3,715.20	—	$2,098.26	$16,665.75	$3,715.20	2026-05-09
55724021121	OTHER	Eucrisa	44	13	$3,661.87	—	$5.00	$16,665.75	$3,661.87	2026-05-09
69018821	OTHER	Ibrance	44	13	$3,653.12	—	$34.80	$16,665.75	$3,653.12	2026-05-09
55513084301	OTHER	Erenumab-aooe	44	13	$3,612.58	—	$9.21	$16,665.75	$3,612.58	2026-05-09
60793090910	OTHER	Thrombi-gel 100 Cm2	43	13	$3,556.46	—	$3,289.72	$16,665.75	$3,556.46	2026-05-09
51759020210	OTHER	Ajovy Autoinjector	44	13	$3,519.16	—	$5.00	$16,665.75	$3,519.16	2026-05-09
51759020410	OTHER	Ajovy 225 mg/1.5mL Syringe	44	13	$3,519.16	—	$9.36	$16,665.75	$3,519.16	2026-05-09
480372056	OTHER	Pyrimethamine	43	13	$3,420.00	—	$3,163.50	$16,665.75	$3,420.00	2026-05-09
2143611	OTHER	Galcanezumab-gnlm Pen	44	13	$3,390.58	—	$7.57	$16,665.75	$3,390.58	2026-05-09
50419052435	OTHER	Betaseron	44	13	$3,343.82	—	$19.56	$16,665.75	$3,343.82	2026-05-09
49471000105	OTHER	Pre-pen .25 Ml	43	13	$3,244.80	—	$3,001.44	$16,665.75	$3,244.80	2026-05-09
78056751	OTHER	Afinitor 10 Mg	44	13	$3,200.31	—	$5.00	$16,665.75	$3,200.31	2026-05-09
173088710	OTHER	Trelegy Ellipta 100-62.5	43	13	$3,156.86	—	$2,920.09	$16,665.75	$3,156.86	2026-05-09
23923201	OTHER	Botox Cosmetic	44	13	$3,148.80	—	$1,051.20	$16,665.75	$3,148.80	2026-05-09
78068715	OTHER	Promacta	43	13	$3,147.39	—	$2,911.34	$16,665.75	$3,147.39	2026-05-09
13533063402	OTHER	Hypertet S-d 250 Unit	44	13	$3,116.02	—	$547.78	$16,665.75	$3,116.02	2026-05-09
23114501	OTHER	Botox 100 Unit	44	13	$3,100.80	—	$33.44	$16,665.75	$3,100.80	2026-05-09
310461612	OTHER	Budesonide/Glycopyr/Formoterol	44	13	$3,096.67	—	$347.23	$16,665.75	$3,096.67	2026-05-09
58914030180	OTHER	Rectiv	43	13	$3,075.55	—	$2,844.89	$16,665.75	$3,075.55	2026-05-09
299598035	OTHER	Mirvaso	43	13	$3,060.10	—	$2,830.59	$16,665.75	$3,060.10	2026-05-09
70510217102	OTHER	Radicava	43	13	$3,053.81	—	$2,824.78	$16,665.75	$3,053.81	2026-05-09
60793070210	OTHER	Bicillin L-a 2400000 Unit	44	13	$2,999.86	—	$680.00	$16,665.75	$2,999.86	2026-05-09
50458030611	OTHER	RisperDAL Consta 25 Mg	43	13	$2,949.89	—	$2,728.65	$16,665.75	$2,949.89	2026-05-09
43598000451	OTHER	Augmentin	44	13	$2,935.68	—	$14.64	$16,665.75	$2,935.68	2026-05-09
60793090701	OTHER	Thrombi-gel 10 Cm2	43	13	$2,931.41	—	$2,711.55	$16,665.75	$2,931.41	2026-05-09
72511077001	OTHER	Evolocumab 420 mg/3.5mL	44	13	$2,919.74	—	$505.28	$16,665.75	$2,919.74	2026-05-09
3085222	OTHER	SpryceL	43	13	$2,919.41	—	$2,700.45	$16,665.75	$2,919.41	2026-05-09
61958290102	OTHER	Veklury	43	13	$2,877.50	—	$2,661.69	$16,665.75	$2,877.50	2026-05-09
51672137108	OTHER	clobetasoL Propionate	44	13	$2,842.36	—	$422.76	$16,665.75	$2,842.36	2026-05-09
43235	OTHER	Upper Gastro/Endoscopy	43	13	$2,834.00	—	$2,621.45	$16,665.75	$2,834.00	2026-05-09
57962042028	OTHER	Imbruvica	44	13	$2,809.99	—	$85.00	$16,665.75	$2,809.99	2026-05-09
31622	OTHER	Rt Bronchoscopy	43	13	$2,803.24	—	$2,592.99	$16,665.75	$2,803.24	2026-05-09
59353040509	OTHER	Methoxy Peg-epoetin 200 Mcg/0.	43	13	$2,769.36	—	$2,561.66	$16,665.75	$2,769.36	2026-05-09
69238101302	OTHER	Testosterone	43	13	$2,682.88	—	$2,481.66	$16,665.75	$2,682.88	2026-05-09
9379401	OTHER	Corvert	44	13	$2,634.48	—	$11.80	$16,665.75	$2,634.48	2026-05-09
A0426	HCPCS	Amb Non Emr Als Rnd Trip	44	13	$2,600.00	—	$92.32	$16,665.75	$2,600.00	2026-05-09
59148002150	OTHER	Samsca 30 Mg	43	13	$2,590.29	—	$2,396.02	$16,665.75	$2,590.29	2026-05-09
55513020901	OTHER	Neupogen	43	13	$2,550.86	—	$2,359.55	$16,665.75	$2,550.86	2026-05-09
85433101	OTHER	Noxafil	43	13	$2,546.16	—	$2,355.20	$16,665.75	$2,546.16	2026-05-09
61953000403	OTHER	Flebogamma Dif	44	13	$2,541.12	—	$1,619.80	$16,665.75	$2,541.12	2026-05-09
63323064810	OTHER	Levothyroxine Sodium	44	13	$2,533.97	—	$170.28	$16,665.75	$2,533.97	2026-05-09
597016061	OTHER	Spiriva Respimat	43	13	$2,531.47	—	$2,341.61	$16,665.75	$2,531.47	2026-05-09
5200010	OTHER	Pneumoc 20-val Conj-dip Crm/Pf	43	13	$2,503.78	—	$2,315.99	$16,665.75	$2,503.78	2026-05-09
59148002050	OTHER	Samsca 15 Mg	43	13	$2,496.95	—	$2,309.68	$16,665.75	$2,496.95	2026-05-09
78206018401	OTHER	Adalimumab-bwwd	44	13	$2,491.20	—	$15.16	$16,665.75	$2,491.20	2026-05-09
50090073200	OTHER	Advair Diskus	44	13	$2,486.88	—	$1.50	$16,665.75	$2,486.88	2026-05-09
43247	OTHER	Egd Flx Transoral W/for Bdy Rm	44	13	$2,476.53	—	$550.00	$16,665.75	$2,476.53	2026-05-09
24208050405	OTHER	Vyzulta	43	13	$2,451.17	—	$2,267.33	$16,665.75	$2,451.17	2026-05-09
71571033383	OTHER	Loteprednol Etabonate 0.25% Op	43	13	$2,438.50	—	$2,255.61	$16,665.75	$2,438.50	2026-05-09
49084	OTHER	Paracentesis	43	13	$2,428.80	—	$2,246.64	$16,665.75	$2,428.80	2026-05-09
10631009160	OTHER	Eurax	44	13	$2,428.42	—	$5.00	$16,665.75	$2,428.42	2026-05-09
51991082328	OTHER	Everolimus	44	13	$2,422.24	—	$5.00	$16,665.75	$2,422.24	2026-05-09
23320505	OTHER	Bimatoprost 0.01% 5ml	44	13	$2,412.34	—	$41.95	$16,665.75	$2,412.34	2026-05-09
55513054610	OTHER	Neupogen 480 Mcg	43	13	$2,406.38	—	$2,225.90	$16,665.75	$2,406.38	2026-05-09
378932232	OTHER	Wixela Inhub 500/50	43	13	$2,362.52	—	$2,185.33	$16,665.75	$2,362.52	2026-05-09
597002402	OTHER	Combivent Respimat	44	13	$2,348.83	—	$46.90	$16,665.75	$2,348.83	2026-05-09
55566830301	OTHER	Firmagon	44	13	$2,344.56	—	$116.54	$16,665.75	$2,344.56	2026-05-09
68546032512	OTHER	Copaxone 40 Mg	44	13	$2,332.80	—	$71.09	$16,665.75	$2,332.80	2026-05-09
173086910	OTHER	Anoro Ellipta	44	13	$2,279.23	—	$5.84	$16,665.75	$2,279.23	2026-05-09
597008717	OTHER	Atrovent Hfa	44	13	$2,265.89	—	$5.00	$16,665.75	$2,265.89	2026-05-09
24208053535	OTHER	Zirgan	43	13	$2,256.34	—	$2,087.11	$16,665.75	$2,256.34	2026-05-09
55513002304	OTHER	Aranesp 60 Mcg	44	13	$2,229.12	—	$32.88	$16,665.75	$2,229.12	2026-05-09
55513000404	OTHER	Aranesp	44	13	$2,229.12	—	$390.00	$16,665.75	$2,229.12	2026-05-09
713063337	OTHER	metroNIDAZOLE 0.75 %	43	13	$2,199.48	—	$2,034.52	$16,665.75	$2,199.48	2026-05-09
49281019020	OTHER	Imogam Rabies-ht 150 Unit	44	13	$2,172.31	—	$1,320.80	$16,665.75	$2,172.31	2026-05-09
46087221	OTHER	Premarin .625 Mg	43	13	$2,160.24	—	$1,998.22	$16,665.75	$2,160.24	2026-05-09
14789001101	OTHER	Isoproterenol Hcl Inj	44	13	$2,160.00	—	$241.68	$16,665.75	$2,160.00	2026-05-09
99999998396	OTHER	Tacrolimus 0.5mg/mL - 240mL Bo	43	13	$2,140.80	—	$1,980.24	$16,665.75	$2,140.80	2026-05-09
69130904	OTHER	Retacrit	43	13	$2,117.76	—	$1,958.93	$16,665.75	$2,117.76	2026-05-09
173071720	OTHER	Advair Hfa 230-21mcg	44	13	$2,110.66	—	$5.00	$16,665.75	$2,110.66	2026-05-09
61314032601	OTHER	Zarxio	43	13	$2,107.10	—	$1,949.07	$16,665.75	$2,107.10	2026-05-09
37683015	OTHER	Cortifoam 10 %	44	13	$2,105.28	—	$1,215.55	$16,665.75	$2,105.28	2026-05-09
78068615	OTHER	Promacta	43	13	$2,098.26	—	$1,940.89	$16,665.75	$2,098.26	2026-05-09
49281025051	OTHER	Imovax Rabies Vaccine 2.5 Unit	44	13	$2,082.29	—	$222.36	$16,665.75	$2,082.29	2026-05-09
59353040409	OTHER	Methoxy Peg-epoetin 150 Mcg/0.	43	13	$2,077.01	—	$1,921.23	$16,665.75	$2,077.01	2026-05-09
61958080101	OTHER	Letairis	44	13	$2,076.89	—	$22.61	$16,665.75	$2,076.89	2026-05-09
46287002004	OTHER	Carospir	44	13	$2,074.56	—	$222.05	$16,665.75	$2,074.56	2026-05-09
42023021910	OTHER	Vasopressin 40 units/100mL	43	13	$2,038.80	—	$1,885.89	$16,665.75	$2,038.80	2026-05-09
173052100	OTHER	Salmeterol Xinafoate	43	13	$2,032.61	—	$1,880.16	$16,665.75	$2,032.61	2026-05-09
90945	OTHER	Peritoneal Dialysis	44	13	$2,013.75	—	$72.38	$16,665.75	$2,013.75	2026-05-09
51224001210	OTHER	Phentolamine Mesylate 5 Mg	43	13	$2,006.40	—	$1,855.92	$16,665.75	$2,006.40	2026-05-09
60793090804	OTHER	Thrombi-gel 40 Cm2	43	13	$1,957.87	—	$1,811.03	$16,665.75	$1,957.87	2026-05-09
173091610	OTHER	Fluticasone/Vilanterol 50-25 M	44	13	$1,954.66	—	$57.12	$16,665.75	$1,954.66	2026-05-09
173088210	OTHER	Breo Ellipta	44	13	$1,954.66	—	$1,681.92	$16,665.75	$1,954.66	2026-05-09
93318	OTHER	Tee	43	13	$1,931.00	—	$1,786.17	$16,665.75	$1,931.00	2026-05-09
63459091211	OTHER	Granix 480 Mcg	44	13	$1,919.44	—	$346.22	$16,665.75	$1,919.44	2026-05-09
456270010	OTHER	Avycaz 2.5 Gram	44	13	$1,898.81	—	$12.23	$16,665.75	$1,898.81	2026-05-09
23932110	OTHER	Alphagan P - 10mL	44	13	$1,865.76	—	$1.50	$16,665.75	$1,865.76	2026-05-09
68982085001	OTHER	Octagam	43	13	$1,864.80	—	$1,724.94	$16,665.75	$1,864.80	2026-05-09
168016360	OTHER	clobetasoL Propionate 0.05% Cr	44	13	$1,835.84	—	$7.32	$16,665.75	$1,835.84	2026-05-09
597013830	OTHER	Gilotrif	44	13	$1,831.73	—	$230.25	$16,665.75	$1,831.73	2026-05-09
8065183905	OTHER	Viscoat 40-30mg/ml	43	13	$1,830.14	—	$1,692.88	$16,665.75	$1,830.14	2026-05-09
81284052201	OTHER	Penicillin G Benzathine	43	13	$1,824.00	—	$1,687.20	$16,665.75	$1,824.00	2026-05-09
A0429	HCPCS	Amb Emr Bls One Way	44	13	$1,800.00	—	$167.28	$16,665.75	$1,800.00	2026-05-09
378932132	OTHER	Wixela Inhub 250/50mcg	43	13	$1,796.32	—	$1,661.60	$16,665.75	$1,796.32	2026-05-09
46074905	OTHER	Premarin 25 Mg	43	13	$1,766.64	—	$1,634.14	$16,665.75	$1,766.64	2026-05-09
51672130308	OTHER	Econazole Nitrate 1% Cream	44	13	$1,738.80	—	$177.17	$16,665.75	$1,738.80	2026-05-09
23391950	OTHER	Botox Cosmetic	44	13	$1,737.60	—	$1,051.20	$16,665.75	$1,737.60	2026-05-09
24208060203	OTHER	Prolensa	43	13	$1,712.98	—	$1,584.51	$16,665.75	$1,712.98	2026-05-09
310461639	OTHER	Breztri Aerosphere 160-9-4.8	44	13	$1,707.60	—	$9.64	$16,665.75	$1,707.60	2026-05-09
78060715	OTHER	Gilenya	44	13	$1,701.03	—	$1,573.45	$16,665.75	$1,701.03	2026-05-09
173087310	OTHER	Incruse Ellipta	44	13	$1,699.68	—	$45.47	$16,665.75	$1,699.68	2026-05-09
66993087761	OTHER	Calcipotriene	44	13	$1,694.76	—	$163.55	$16,665.75	$1,694.76	2026-05-09
70557	OTHER	MRI - Brain Without Contrast	43	13	$1,686.00	—	$1,559.55	$16,665.75	$1,686.00	2026-05-09
6382310	OTHER	Cancidas	44	13	$1,684.22	—	$417.60	$16,665.75	$1,684.22	2026-05-09
69029201	OTHER	Nivestym 480mcg/0.8 Ml	43	13	$1,681.92	—	$1,555.78	$16,665.75	$1,681.92	2026-05-09
51672129502	OTHER	Diflorasone Diacetate 0.05% Oi	44	13	$1,677.40	—	$5.00	$16,665.75	$1,677.40	2026-05-09
51672129602	OTHER	Diflorasone Diacetate 0.05% Cr	44	13	$1,677.40	—	$5.00	$16,665.75	$1,677.40	2026-05-09
72252051002	OTHER	diazePAM Nasal Spray	44	13	$1,672.85	—	$1,547.38	$16,665.75	$1,672.85	2026-05-09
24338013402	OTHER	E.e.s. Granules (Bulk)	80	13	$1,805.86	—	$18.04	$16,665.75	$1,670.42	2026-05-09
59353040709	OTHER	Methoxy Peg-epoetin 120 Mcg/0.	43	13	$1,661.62	—	$1,537.00	$15,797.76	$1,661.62	2026-05-09
64980032802	OTHER	Erythromycin/Benzoyl Peroxide	44	13	$1,659.16	—	$5.00	$15,797.76	$1,659.16	2026-05-09
70727052925	OTHER	Rocklatan 0.02-0.005%	43	13	$1,647.84	—	$1,524.25	$15,797.76	$1,647.84	2026-05-09
59148008213	OTHER	Jynarque	44	13	$1,645.69	—	$30.15	$15,797.76	$1,645.69	2026-05-09
69015111	OTHER	Inlyta	44	13	$1,643.65	—	$26.00	$15,797.76	$1,643.65	2026-05-09
6382210	OTHER	Cancidas	44	13	$1,621.01	—	$432.00	$15,797.76	$1,621.01	2026-05-09
3052411	OTHER	SpryceL	43	13	$1,619.80	—	$1,498.32	$15,797.76	$1,619.80	2026-05-09
16729012953	OTHER	Temozolomide	43	13	$1,611.46	—	$1,490.60	$15,797.76	$1,611.46	2026-05-09
55513092491	OTHER	Neupogen	43	13	$1,601.76	—	$1,481.63	$15,797.76	$1,601.76	2026-05-09

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